Healthcare Provider Details

I. General information

NPI: 1306819230
Provider Name (Legal Business Name): LAKE REGION UROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 GENESEE ST
AUBURN NY
13021-3361
US

IV. Provider business mailing address

192 GENESEE ST
AUBURN NY
13021-3361
US

V. Phone/Fax

Practice location:
  • Phone: 315-258-5253
  • Fax: 315-258-0202
Mailing address:
  • Phone: 315-258-5253
  • Fax: 315-258-0202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number195558
License Number StateNY

VIII. Authorized Official

Name: DR. WILLIAM HASTINGS FORESMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 315-258-5253